i am not the least bit offended by kathy's passion. sometimes we do act like dinosaurs and i know how it feels when suggestions fall on deaf ears. at the same time we do have to recognize and respect the efforts of the older nurses who have worked so hard to get us where we are now. that being said i must point out you can find studies to support any position you want if you try hard enough.
>>> "Mary M. Maskell Amirault" <[EMAIL PROTECTED]> 1/31/2006 7:48:15 AM >>> I can appreciate this intellectual banter but find it very unprofessional for you to refer to nurses as "dinasours" and the fact that you hope to see them eliminated is inexcusable. You owe us "dinasours" an apology and should show some respect for paving the way for young mavericks like yourself. Did you ever think that maybe we had a few hurdles to overcome when we started our practice?!!! >>> "Kokotis, Kathy" <[EMAIL PROTECTED]> 1/30/2006 11:54:55 PM >>> Went to the references as suggested. Where are the big physician studies like Howard Chrisman MD out of Northwestern University in Chicago or where is the AHRQ report cited. I realize chrisman's article was from JVIR 1999 but it did include 2,650 catheters. I guess that study which is the standard on ultrasound placement with PICC lines is too old. I guess Dr. Denny who invented the Denny introducer ( interventionalist out of Princeton NJ) said it to me best. All catheters should be placed with US and MST regardless of setting. Dr Hickman told me the same thing in 2003. I agree with both of them. The INS standards on page S38 are a joke!!! When INS is evidenced based in their standards we will talk. Antecubital is no place for a PICC line as it is torturous, small, bundle of nerves lie there, artery, and one does not know if the line threaded basilic or cephalic unless one has x-ray vision. Why would one recommend practice that is based on the early 90's? I can only think they want to continue please the dinosaur nurses who will not move forward. Hopefully those nurses will find themselves outsourced or eliminated in the next five years. As for homecare and nursing homes. Portable ultrasound, modified seldinger technique and tip confirmation is all possible in today's day and age. Midlines are no substitute for PICC lines which is happening now. Changes will occur as we move towards the Medicare "pay for performance initiatives". I very much look forward to Medicare "pay for performance" Kathy ________________________________ From: Lynn Hadaway [mailto:[EMAIL PROTECTED] Sent: Mon 1/30/2006 3:21 PM To: Kokotis, Kathy; Bev and Tim Royer; CAROLYN; [EMAIL PROTECTED] Subject: RE: INS standard # 37 Yes all publications were considered, including those with physician authors. Just look at the reference lists and you can see that easily. There are also statements about using visualization technology for site selection on all types of catheters. So I would suggest you read the standards before making more off-handed statements. We were also careful about the age of a study so it could be that the AHRQ report you are referring to was too old for the established criteria. Lynn At 3:04 PM -0700 1/30/06, Kokotis, Kathy wrote: >You are right that there is no study that looks >at these two methods (traditional peel-away >versus MST & US) side by side in a prospective >randomized, blinded study. There is a large >article that does look side by side at the usage >of ultrasound versus no ultrasound to place PICC >lines in radiology that is prospective, and >radomized, and blinded (Dr. Howard Chrisman). >That article is one of several cited in the AHRQ >report. > >The articles I do use are attached in summary: > >Both hospitals have nursing teams using >traditional insertion and radiology with high >tech tools. The method of insertion is cited in >the body of the study for both groups. Both >studies report the nursing complications rate >separate from radiology complications rate post >insertion. The nursing complication rate was >way higher than the radiology rate. One study >written by RN and one by MD. > >Thrombosis and phlebitis rate was higher for >the nursing insertions in both studies versus >the radiology insertions. That study would >prompt me to send all PICC line insertions to >radiology as there is a significat statistical >difference in thrombosis and phlebitis as >pointed out in Fong and Walshe studies. > >However looking at medicine today why would it >not be mandatory to use US & MST to place all >Central lines regardless of setting. We >therefore are willing to accept bad patient >outcomes if we don't. > >Success rate leading to patiend safety is well >proven and evidence based for the usage of >ultrasound > >That alone is enough for me. > >I think INS should have included the evidenced >based studies for the insertion of PICC lines >with ultrasound found in the AHRQ report. Were >those not considered in writing these standards >or were they insignificant as they were written >by physicians and not nurses. All the studies >cited in the AHRQ report were randomized, >blinded and prospective. You were on the INS >committee. Did these articles not get >considered or the the AHRQ report itself? I >know when the AVA guidelines are released these >articles will be definitely included. All >physician articles will be considered. > >kokotis > > > >________________________________ > >From: Lynn Hadaway [mailto:[EMAIL PROTECTED] >Sent: Mon 1/30/2006 1:23 PM >To: Kokotis, Kathy; Bev and Tim Royer; CAROLYN; [EMAIL PROTECTED] >Subject: RE: INS standard # 37 > > > >Well Kathy, I think that you are still comparing apples and oranges >when you compare IR inserted PICCs to a nurse-inserted service. I >think you are comparing data from multiple studies without going >through the strict analysis processes required for a meta-analysis. > >When we were looking at the published data for the standards, I nor >anyone else on the INS standards committee found an article of any >kind comparing PICCs inserted with the standard through the >introducer to PICCs inserted using MST. You may claim that you can >compare data from multiple studies but until it has gone through a >true meta-analysis process and the peer-reviewed publications >process, it can not be used as a reference in a document such as the >standards. > >I really do not think anyone is arguing that the AC inserted PICCs >are better than the ones placed above the AC, so I think we are >making a mountain out of a mole hill on this one! Lynn > >At 11:54 AM -0700 1/30/06, Kokotis, Kathy wrote: > >I do not know if anyone read my last paper in the LITE spectrum but >>I did address the two papers with looking at complications rates of >>MST & US and upper arm placement vs nursing traditional insertions. > >How did I do this. IR used upper arm and MST and ultrasound and >>nursing used traditional tools. Phlebitis rates, thrombosis rates >>were higher for nurisng group significantly. >> >>If INS does not understand to this day that upper arm basilic >>placement has a lower rate of complications and that usage of >>portable ultrasound is highly recommended and evidence based in the >>AHRQ government safety report than how can I defend practice that is >>so out of date. I can defend what we do not easily as INS is not >>reading the literature >> >>My soap box is over. Get with the times. By the way from my >>figures 45% of PICC lines are placed in nursing with MST and 100% in >>radiology with MST. You do the math. The doctors are right and >>more patient focused. Ultrasound is used 15% in nurisng insertions >>and doctors use fluoro or ultrasound in 100% of cases. I don't know >>about INS but standard of care dictates the usage of US or MST or >>all PICC lines should be send to radiology to be placed. What do >>you think of that one? >>kathy >> >>________________________________ >> >>From: [EMAIL PROTECTED] on behalf of Bev and Tim Royer >>Sent: Sun 1/29/2006 10:02 AM >>To: 'CAROLYN'; [EMAIL PROTECTED] >>Subject: RE: INS standard # 37 >> >> >>When looking at this standard it is important to note that >>Paragraphs II & III A and B which come before paragraph C state: >>A "Site selection criteria should be established in >>organizational policies and procedures and practice guidelines." >>B "Site selection should be determined per manufacturer's labeled >>uses(s) and directions for device insertions." >> >>To me, as a clinician, I am covered under paragraphs A & B if >>placing in the upper arm using ultrasound imaging. >> >>Currently there is very little scientific evidence based practice >>published on the topic of comparing antecubital and upper placement >>of PICCs. Most manuscripts, address increase in successful PICC >>line placement rates in the upper arm using micro-introducer and >>ultrasound imaging technology. Only antedotally is it mentioned >>that there is a decrease in mechanical phlebitis and an increase in >>patient and nursing satisfaction not having the PICC placed in the >>region around the antecubital fossa. >> >>The use of micro-introducers and ultrasound imaging with nursing is >>still only a small percent of the total number of PICCs placed by >>nursing. There are many facilities and agencies that place PICCs >>using the traditional approach of sight and feel and place in the >>antecubital fossa regional and report that they have good outcomes. >>Nurses are good at what they do. >> >>Antedotal evidence is OK and is considered but it is not considered >>rigorous scientific study. Outcome data analysis carries a little >>more weight and should be published more than it is in this area. >>However, like everybody else in our field, our time is so involved >>in patient care and management that publishing is low on our >>priority list. Best would be research in this area involving a more >>rigorous scientific study comparing both areas of placement >>(antecubital fossa vs upper arm). Again our time is limited at work >>and the time involved in getting an approved study through the IRB >>at the facilities we work at and the time necessary to carry out the >>study is very involved and time consuming. Nursing Research is not >>a high priority for many institutions. >> >>We all need to be tracking our data on PICCs and complications and >>have the data published. >> >>Bottom line here - "The Infusion Nursing Standards of Practice", >>revised 2006 edition, cannot put a standard in that is not backed up >>by rigorous scientific study even though antedotally we see better >>outcomes. It has been published over and over again that nurses can >>place PICC lines safely in the antecubital fossa region. >> >>Timothy Royer, BSN, CRNI >>Nurse Manager / Vascular Access / Diagnostic Service > >VA Puget Sound Health Care System >>Seattle / Tacoma, WA >> >>Disclaimer - This are my personal beliefs and do not represent the >>institution I work at. >> >>________________________________ > > >>From: [EMAIL PROTECTED] >>[mailto:[EMAIL PROTECTED] On Behalf Of CAROLYN >>Sent: Sunday, January 29, 2006 7:40 AM >>To: [EMAIL PROTECTED] >>Subject: INS standard # 37 >> >> >># 37 Site Selection - Practice Criteria: II Peripheral-Midline and >>III PICC it states: >> >>Site selection should be routinely initiated in the region of the >>antecubital fossa; veins that should be considered for cannulation >>are the basilic, median cubital, cephalic, and the brachial. >> >>When we use ultrasound we are hardly ever placed in the antecubital >>fossa because of the larger catheters being required, increase in >>antecubital complications because of movement and of course patient >>comfort. >> >>What are the legal implications of this in court by not using the >>antecubital for placement? Thanks >> >>Upgrade Your Email - Click here! >><> >> > > >-- >Lynn Hadaway, M.Ed., RNC, CRNI >Lynn Hadaway Associates, Inc. >126 Main Street, PO Box 10 >Milner, GA 30257 >http://www.hadawayassociates.com >office 770-358-7861 > > > >Content-Type: application/msword; > name="Published evidence usage of MST and ultrasound.doc" >Content-Description: Published evidence usage of MST and ultrasound.doc >Content-Disposition: attachment; > filename="Published evidence usage of MST and ultrasound.doc" > >Attachment converted: G4 Laptop:Published >evidence u#1455BB.doc (WDBN/«IC») (001455BB) -- Lynn Hadaway, M.Ed., RNC, CRNI Lynn Hadaway Associates, Inc. 126 Main Street, PO Box 10 Milner, GA 30257 http://www.hadawayassociates.com office 770-358-7861 ----------------------------------------- CONFIDENTIALITY NOTICE: This email and any attachments may contain confidential information that is protected by law and is for the sole use of the individuals or entities to which it is addressed. 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